The anatomy of a suicide in the Humboldt County Jail

In January, journalism students from HSU, as part of an investigative reporting class taught by Assistant Professor Marcy Burstiner, set out to understand the intersection of the mental health and criminal justice systems in Humboldt County by investigating the death of one man: James Lee Peters, a Hoopa resident who committed suicide in the Humboldt County Jail last August. Over three months they intended to interview people who knew him as well as people who work in mental health and criminal justice. They were met with a wall of silence: Many people did not respond to repeated requests for information. People in the mental health field who did respond said they could not discuss his case because of privacy protections required under federal law. His lawyers argued that attorney-client privilege survives the death of a client. The Hoopa community, unused to anything but negative news, did not feel comfortable talking about Peters to the press.

The mental health system in Humboldt and across the state turned out to be a labyrinth they couldn't penetrate; instead of answering basic questions about standard procedures one agency after another bounced them from office to office. A public information officer at Atascadero State Hospital forced them to file a California Public Records Request just to find out how its trial competency program works.

So the students poured through records: Court minutes and files that are open to public inspection; birth, death and autopsy reports; court transcripts, case files released from the district attorney's office in response to another public records request and procedural reports and data from Atascadero. Their conclusion based on the records and interviews: The untimely death of James Lee Peters was both entirely preventable and inevitable. It reflected the inability of our mental health system to help people until it is too late, and the failure of the criminal justice system to handle the people who end up in the jails as a result.

James Lee Peters spent his 25th birthday last August behind the walls of the Humboldt County Jail, waiting to be taken to a state mental hospital. He spent his previous birthday much the same way. He wouldn't live to see the next. Instead, 10 days after he turned 25, Peters took the sheet off his bed, tore it into strips, tied them together and hanged himself. He would be on life support for eight days at St. Joseph Hospital before he would die of asphyxiation.

If Peters understood what he was doing when he ended his life, it might have been the only time he fully understood his actions. Complications at birth gave him learning disabilities and a low IQ. Throughout his life he needed mental health counseling but received little. He tended to lash out when he was angry and that repeatedly put him in trouble with the law. What began as small outbursts became increasingly violent, until the criminal justice system could no longer overlook the threat he represented. Instead, as his criminal record piled up, the Humboldt County Superior Court bounced him between a variety of mental health facilities, but only to make him competent enough to stand trial.

But this story doesn't stop with Peters. Because the tragedy is that we fill our jail, and jails across the state and country, with people just like him. There are alternatives, but not in Humboldt County.

"This community treats dogs better then the mentally ill," said District Attorney Paul Gallegos. "My hope is that we [would] treat our mentally ill better than we treat a dog."

What little we know about James Lee Peters plays out through documents obtained under the California Public Records Act. Everyone he interacted with, from teachers, police officers, lawyers, doctors, counselors, probation officers and jail guards refused to speak about him or his particular case for this story. Neither would members of his family, who still grieve over his death and who intend to file suit against any party they can find responsible. As of yet, no lawsuit has been filed.

Here's what we do know. James Lee Peters, nicknamed Hans, was a Yurok Indian from Hoopa who entered the world much the same way he would leave it: gasping for air.

At birth Peters was without oxygen for several minutes. That manifested into developmental and cognitive problems. Jamie Lynn Solano gave birth to Peters at age 16; he was the first of her three children. His biological father did not acknowledge him and the first years of his life weren't easy. He suffered physical abuse and several members of his family battled with drug and alcohol problems. Sometime in his childhood Peters saw a counselor briefly in Hoopa but stopped because the family feared he would be taken from his mother. Around age five, social workers took him from his mother and he went to live with his grandmother Joyce Croix, whom Peters credited with raising him.

If you drive easton Highway 299 and head north on Highway 96 through dense redwood forests, you will descend into the Hoopa Valley. Here a Ray's Food and the Lucky Bear Casino stand against a backdrop of jagged mountains. Nearby, the Trinity River flows past grounds where Hoopa residents still hold ancient healing and renewal ceremonies, such as the sacred Jump Dance and Boat Dance.

With about 2,600 people on 144 square miles, Hoopa is at once the state's largest Indian reservation and a small town where everyone knows everyone. The sovereign nation is separated from the rest of the county by both distance and culture. The tribal government administers health services on the reservation, including some drug, alcohol and mental health treatment, but offers no residential treatment facility. It educates students in conjunction with the Klamath-Trinity Joint Union School District.

Peters had a difficult time learning, so he was put in special education classes at Hoopa Valley Elementary. His fourth-grade yearbook picture shows a dark-haired boy with a big smile. The picture of him in fifth grade shows an 11-year-old boy standing straight and looking proud. (Few of the people who knew Peters at that age were willing to speak of him on the record. Most of what follows comes from reports written later by officials and psychologists who interacted with him at various stages in his journey through the criminal justice system.)

In the ninth grade, his grandmother died. Peters later said that that period in his life was emotionally difficult for him, and as a result he had trouble in school. He was involved in three physical fights, was caught with marijuana, and was expelled.

At 14, psychological evaluations determined that his verbal comprehension was "particularly impaired." He continued his education at Captain John Continuation High School in Hoopa, and was shuffled between the homes of various members of his extended family. But he lacked a primary guardian.

The lack of guidance took its toll. At 16, he picked up a rock and threw it at a teacher's car, cracking the windshield. Police charged him with battery of a school employee and he served 60 days in Juvenile Hall. In throwing that rock he threw himself into the Humboldt County criminal justice system and he would never climb out of it.

The Hoopa Valley Tribal Police station has no holding cell. Each time a suspect is arrested police drive him 60 miles to the county jail in Eureka. Taking someone that far for relatively minor crimes adds a "traumatic element" to an already traumatic situation, said Graham Hill, chief of the Rio Dell police department. While Rio Dell sits at the opposite end of the county, his department also lacks a holding cell. The drive from Rio Dell to Eureka is just 25 miles, but that extra trauma, he said, can do more harm in the long run for prisoners who are mentally ill. The geographic distance also makes it difficult for family to visit prisoners in the county jail.

Peters soon added two more infractions — criminal threat of assault and battery and assault with a deadly weapon — to his juvenile record. About that time, he landed his first and only job, that of a choker setter for Three Star Logging Company, a typical entry level job in the logging business.

As a choker setter, he would likely have trudged up hillsides machines could not access, to wrap a cable under and around a log, forming a noose so that they could be pulled up to a place where they can be put on a truck. It is not an easy job, said Robert VanNatta, part owner of a 30-year-old logging business in Apiary, Ore.

While VanNatta didn't employ Peters or know of him, he could explain the type of work Peters likely had. "You cannot exaggerate the difficulty and danger of choker setting," VanNatta said. After securing the noose, the choker setter must quickly get away or risk getting crushed from rolling logs. Peters liked manual labor, but quit after he was denied a $1.25 an hour raise. That marked the end of his employment and education.

Unable to control his anger or impulses, his offenses became increasingly serious. As an adult numerous evaluations found that he suffered from Paranoid Personality Disorder, mild mental retardation and schizophrenia. At 24, his IQ was 67, which is the equivalent to that of an average 11-year-old child. Only 2.3 percent of the population possess IQs lower than 70.

His trouble deepened in 2001. Between October of that year and August 2002, he would be arrested five times. In two of those cases he assaulted women. In one he threatened a woman with great bodily injury. As a result of those arrests, he was sentenced to a 52-week batterer's program that he would never complete, and three years probation. When released, he became a statistic.

Megan Gotcher was Hans Peters' probation officer and is now a senior officer for the Humboldt County Probation Department. There are more than 50 officers in the county, but each officer is responsible for 60-100 probationers at a time.

"If you have a hundred cases, it is hard," Gotcher said. "You deal with searches, subpoenas and home contracts. Sometimes you just have to put out the fire." Probation officers work closely with Hoopa Human Services, but are not trained in mental health services.

The Humboldt County Superior Court questioned Peters' mental health in Dec. 2001 and placed him on two years of conditional release under a program run by the county's Department of Health and Family Services. It was responsible for providing Peters with treatment and supervision while he lived in his community.

But whatever supervision it gave him wasn't enough. In Aug. 2003, police arrested him for pushing his mother and assaulting a friend of hers with a shovel, sending him to the hospital. Around that time a car accident left him with major injuries. Peters would later tell a probation officer that after the accident, he more easily lost his temper and experienced suicidal feelings.

That January, police arrested him for trespassing and vandalism. A month later, they arrested him again for attacking a man with an iron. He was sentenced to three more years probation, but this time the court ordered him to enroll with the Redwood Coast Regional Center, a private, non-profit referral agency for the treatment of people with developmental disabilities, and to participate in a counseling program run by psychologist Karl Fisher through the Hoopa Valley Tribe's Division of Human Services. While waiting for the regional center to evaluate him, he attacked an inmate and in another incident was charged with attacking a custodial officer.

Finally, in April 2004, Eureka clinical psychologist Otto Vanoni evaluated Peters and suggested that his problem was medical rather than criminal and that he belonged in a medical facility rather than a jail.

Peters was housed in isolation during the time of the evaluation, which worsened his condition, Vanoni wrote. "A failure to move him from solitary confinement and a continuation of jailing will only lead to further decomposition of functioning," Vanoni wrote. Vanoni described Peters at the time as having short brown hair, brown eyes, a mustache and "a fuzzy chin beard." At five feet, eleven inches, he weighed 155 pounds. Most important for the court, Vanoni deemed Peters mentally incapable of assisting in his own defense.

Five residential treatment facilities in California specifically treat people with developmental disabilities, but as a criminal, Peters needed to be put into a secured facility. So the Redwood Coast Regional Center sent him to the only secured facility — Porterville Developmental Center, in Tulare County, 520 miles from Hoopa.

After six months, doctors at Porterville deemed him competent and sent him to a "licensed board and care facility," according to court records. (The records don't identify the facility.) In June 2005, the regional center asked the court to terminate his commitment and release him. It argued that Peters was no longer eligible for its services as he was not developmentally disabled. In doing so it contradicted Vanoni's report a year earlier and its own subsequent finding that Peters was eligible for its services based on his diagnoses of mild mental retardation.

"It is believed now that Mr. Peters' mental status at that time of RCRC's psychological evaluation while he was incarcerated affected the results of that testing," wrote Wendy Stout, an intensive services specialist for the regional center at that time. Plus, Stout noted, Peters had not caused trouble in the eight months he'd spent in residential treatment. In layman's terms, being in jail had made Hans Peters crazy, and that tainted the psychological evaluation.

In an interview this month, San Francisco forensic psychologist Paul Good said mental retardation is a "static condition" that doesn't change and can't be cured. And as far as the courts are concerned, a competent person understands the legal process, the roles of courtroom players, legal strategies and can work with an attorney in an effective way. A person can be competent in understanding the law, but that doesn't mean they are mentally healthy.

Five months after his release, however, his anger got the best of him again. In Nov. 2005, he went to a house to talk to a woman he'd been dating. When she said she didn't want to see him, he refused to leave. Her family tried to force him out and Peters reacted by pushing a 13-year-old boy. The boy fell and injured his back against a stool. Police issued an arrest warrant, charging Peters with misdemeanor cruelty to a child.

Back in jail, things got worse. In January 2006, correctional officer Steve Christian opened the door to Peters cell to get some janitorial items and Peters punched him in the face. When officers asked him why he did it he said, "Leave me the fuck alone. Dealing with the voices in the back of my head is hard enough, I don't need to listen to you as well."

Peters later expressed remorse and apologized for his sudden outburst at Christian. "A lot of things were messin' with my head," he said. "I feel bad. No one deserves to get punched."

Again, his lawyers questioned Peters' competency and Judge Christopher Wilson ordered another evaluation. During the two years that preceded his death, Peters, whom doctors said was mentally unable to assist in his own defense, appeared in court 25 times. Five different defense attorneys represented him and he faced 10 different deputy district attorneys and three different judges. It seemed as if Peters was the hat that everyone would pass but no one would wear.

The inability to get Peters the help he so obviously needed frustrated Judge Wilson. Over the next 18 months, Wilson would repeatedly order Peter's attorneys to get him into a local treatment program or a state hospital only to be told that no place would take him. For almost three months in the beginning of 2006, Peters sat in jail while Wilson waited for the California Department of Mental Health to determine if he qualified for conditional release. In February, Eureka clinical psychologist Michael M. Ramirez determined that Peters' was still incompetent to stand trial.

But in March, the Redwood Coast Regional Center again found Peters ineligible for their services. Meanwhile Atascadero rebuffed Wilson's order and refused to take Peters.

On Nov. 6 the court acknowledged that Peters was there too long. "I'd like to know when Napa's going to come get Mr. Peters," Wilson said in court. "They said they're going to reject him because he's mentally disabled. We sent him back to the regional center. They said he's not disabled. They're just playing games with us."

Finally on Dec. 4, 2006, almost a year after his arrest, Peters was transferred to Napa State Hospital. But again, the goal was only to make him competent enough to assist in his own defense, not to silence the voices in his head. He would spend two months there and when doctors deemed him competent, he was back in the jail.

The delays Peters went through are common for the mentally ill prisoners who fill the jail, said Humboldt County Deputy District Attorney Wesley Keat, Jr. in an interview in April of this year. "Those in jail have some kind of mental illness and jailers say the jail is a mental health facility," he said. " There are a lot of people in the County Jail waiting to be transferred to a mental health facility."

The problem is that the jail is not equipped to handle such problematic prisoners, said Brenda Godsey, public information officer for the Humboldt County Sheriffs Office. "We are not a mental health facility," she said.

Humboldt Countyisn'tthe only place with this problem. One study published in 2006 estimated that jails across the country house more than 94,000 people with severe mental illness. The Los Angeles Daily News reported in April that the psychiatric patients who fill most of the 1,000 beds in Los Angeles County's Twin Towers jail facilities have turned the jail into the largest mental institution west of the Mississippi. It cited data that show that statewide, California has just 6,285 beds for mentally ill patients or 17 for every 100,000 residents. Researchers said the state needs at least 12,200 more.

The U.S. House of Representatives passed the Mentally Ill Offender Treatment and Crime Reduction Reauthorization and Improvement Act of 2008. If passed by the Senate, it would provide grants for diversion programs and increase cooperation between the criminal justice and mental health systems.

At least 13 counties in California rely on special courts for mentally ill prisoners to ease the burden. These courts only accept criminal offenders with severe mental problems and dismiss charges after the offender commits to and completes an individualized program designed for their illness, most often one that involves a residential treatment facility. After a year of sobriety and being crime-free, the defendant attends a trial and the case is dismissed. They are then given job training and GED exam preparation.

In Gainesville, Ga., a mental health court entitled HELP (an acronym for Health, Empowerment, Linkage and Possibilities.) puts prisoners on a plan for success, which includes, among other things, getting a job and taking medications. According to an article in the Gainesville Times, prosecutors, defense attorneys, case managers, treatment providers and judges work together to ensure that the prisoners stay on the right path. They review each case in weekly meetings, and determine which ones progress and which ones seem to regress.

California voters tried to address the problem back in 2004 when they passed Proposition 63, also known as the Mental Health Services Act. The statute raised an additional 1 percent tax on the 30,000 state residents (1 percent of the state population) that make an annual income of over $1 million. By 2006, the statute generated about $730 million for mental health services in California. But the law did not specifically fund mental health courts. Mental health providers across the state, and in Humboldt County in particular, complain that much more funding is needed.

A new program known as STAR (Supervised Treatment After Release) started in Humboldt County on April 1, 2007. The goal of the program is to provide evidence-based treatment in treating seriously mentally ill offenders by coordinating mental health service providers, corrections, probation, the district attorney's office, defense attorneys and community/family advocates.

The STAR program only serves 25 offenders at a time, according to its website. Regardless, Peters may have been ineligible, as it does not take inmates considered a public safety threat.

Julie Ohnemus, mental health director of the Open Door Community Health Centers said that in the past five years she has seen a jump in the number of mentally ill patients. The Arcata clinic alone sees 4,000 such patients a month, and that means that counselors can see each patient for only about 15 minutes each. That's not enough time for a doctor to properly monitor a patient. But resources are limited. The Open Door network has a total of eight counselors for both Humboldt and Del Norte counties. That's forced family practitioners to act as psychological counselors.

Hans Peters did not go to an Open Door clinic. But Ohnemus said that the clinics see people like Peters every day, released from the jail and bound to return. That's because the jail releases prisoners who suffer from severe mental conditions without any medication, and without medication they are in no condition to get themselves the help they need. "That's wrong," she said. "There's no reason not to follow up," she said.

Robynne Lute has worked as a behavior health consultant at the Humboldt Open Door since 2004. She sees about 10 patients every day. They suffer from depression, anxiety, substance abuse and chronic pain. She has lost five patients to suicide and several others to drug overdoses. One female patient hanged herself while on a waiting list for county psychiatric services.

"People are not getting what they need," she said. The county has an intensive treatment program but it only has 12 beds for three counties. There is also an emergency treatment program that can keep someone under surveillance for 72 hours. But after that it refers them to other facilities and leaves it to the patient to follow through. Meanwhile, the shortage of beds means that only people who are very sick are admitted into the two programs. "We don't have a lot of services for people that fall in between."

Perhaps Hans Peterswas doomedfrom the start. Although suicide is taboo in the Hoopa Valley Tribe as well as many Native American cultures, rates are high and rising. The Centers for Disease Control reported in 2005 that that among American Indians/Alaska Natives ages 15 to 34 years old, suicide is the second leading cause of death and the per capita rate of 21.4 per 100,000 people is 1.9 times higher than the national average for that age group. Native Americans are disproportionately represented in the Humboldt jail. On the day Peters hanged himself, the jail housed 47 Native American men accounting for 16 percent of the total jail population. Native Americans account for just six percent of the total population in Humboldt County according to a 2006 U.S. Census estimate.

If he could have been steered to an alternate fate, it would likely have had to happen early on. But deputy public defender Christina Allbright described current California law regarding minors and mental incompetency as a "huge black hole." She noted that Humboldt County has no facility to treat mentally incompetent juvenile offenders.

Some in the U.S. Congress are trying to bolster resources for Native Americans. The U.S. Senate passed the Indian Health Care Improvement Act in February. If passed by the House it would fund greater mental health services for tribes and could address the need for in-patient mental health treatment in Hoopa.

Hans Peters wanted to get treated. After Napa released him in March 2007 he told Judge Wilson that he hoped for a normal life. "I just want to go to my programs and take my medication and do good in life and get me a job, sir," he said.

His defense attorney, David Lee, argued that Peters deserved a chance at freedom. "He's served far more time in custody on all of these charges probably than anybody would have gotten at the onset," Lee told Wilson. "It's nobody's fault he was not able to handle the criminal proceedings for many, many, many, many months based on his mitigating mental condition."

Wilson was reluctant to allow Hans Peters to be released without adequate supervision. "If there's some form of decomposition, we're back to where we were," he said in court. "And that just cost Mr. Peters two years of his life."

The process took so long that Wilson released him three times during the two years to take care of personal business: Once to visit his brother, once to cash some checks and once to go to a dentist for a root canal.

In May 2007, Peters spent two days in Sempervirens Psychiatric Health Facility in Eureka, the only inpatient care facility in Humboldt County, while waiting for acceptance into a drug treatment program.

It's not clear exactly how long Peters spent outside confinement on the last go-around, but he was back in jail June 22, this time charged with false imprisonment and two counts of battery. Yet again, the court questioned his mental capability, ordered another psychological evaluation by Dr. Michael M. Ramirez, waited for a report from the mental conditional release program and ordered Peters recommitted to Napa State Hospital for recovery of trial competency.

According to a report from Deputy Coroner Charles Van Buskirk, Hans Peters did not want to return to Napa. Instead, in an attempt to prove mental competence, he had stopped taking his court-ordered medications. At 3:15 p.m. on Aug. 29, 2007, Peters fashioned a noose out of his bed sheet. Two officers found him hanging in his 7 1/2-by-11 foot jail cell. He had pushed the ends of the cloth strips through the small holes in a ventilation grate over his toilet, using a tool he had made by chewing on a spoon.

The officers tried to resuscitate him, but it is unclear if they were able to get a response from the body. At St. Joseph Hospital, doctors put him on life support but he never regained consciousness.

In ending his life, Peters put a stop to what had become an endless cycle: Arrest, temporary treatment, release and re-arrest. The problem is that the system expects mentally ill people like Peters, a man with the mentality of an 11-year-old boy, who suffered from paranoia and who was incapable of controlling his emotions, to get themselves the help they need.

Rebecca Porteous, a licensed clinical social worker, said she sees people come in and out of jail with recurring mental issues. When the jail releases mentally ill inmates, it instructs them to see a mental health professional. If they do that within the first two weeks, they will continue their medication. But not all do.